Abstract
BackgroundIn high-income countries patients with Huntington disease (HD) typically present to healthcare providers after developing involuntary movements, or for pre-symptomatic genetic testing if at familial risk. A positive family history is a major guide when considering the decision to perform genetic testing for HD, both in affected and unaffected patients. Management of HD is focused upon control of symptoms, whether motor, cognitive, or psychiatric. There is no clear evidence to date of any disease-modifying agents. Referral of families and caregivers for psychological and social support, whether to HD-focused centers, or through virtual communities, is viewed as an important consequence of diagnosis. The experience of healthcare for such progressive neurodegenerative diseases in low- and middle-income nations is in stark contrast with the standard of care in high-income countries.MethodsAn extended family with many members affected with an autosomal dominantly inherited movement disorder came to medical attention when one family member presented following a fall. Apart from one family member who was taking a benzodiazepine for involuntary movements, no other affected family members had sought medical attention. Members of this family live on several resource-limited Caribbean islands. Care of the chronically ill is often the responsibility of the family, and access to specialty care is difficult to obtain, or is unavailable. Computed tomography scan of one patient’s brain revealed severe caudate atrophy and moderate generalized cortical atrophy. Genetic diagnosis of HD was obtained.ResultsThrough family recollection and by direct observation we identified four generations of individuals affected with HD. Outreach programs and collaborations helped to provide medical imaging and genetic diagnosis. Additionally these efforts helped with patient and family support, education, and genetic counseling to many members of this family.ConclusionsAffected members of this family have limited healthcare access, and rely heavily on family support for care. Genetic and clinical diagnosis of these patients was impeded by lack of resources and lack of access to specialty care. Importantly, obtaining a definitive diagnosis has had a positive impact for this family by facilitating genetic counseling, education, community outreach, and dispelling myths regarding this hereditary disease and its progression.
Highlights
In high-income countries patients with Huntington disease (HD) typically present to healthcare providers after developing involuntary movements, or for pre-symptomatic genetic testing if at familial risk
In late stages patients typically require increased care as they shift from their hyperkinetic chorea state, to a rigid hypokinetic phenotype [3], leading to an increased risk for depression among caregivers due to the stress associated with care for HD patients [4]
All interviewed family members were asked about the possibility that they had Venezuelan heritage due to the high HD incidence in the Lake Maracaibo region [5] but we were unable to establish a connection
Summary
In high-income countries patients with Huntington disease (HD) typically present to healthcare providers after developing involuntary movements, or for pre-symptomatic genetic testing if at familial risk. Huntington disease Huntington disease (HD) is a neurodegenerative disorder typically of adult onset, affected individuals typically have children before symptom manifestation. Chorea and psychiatric symptoms are typical, language and memory of past events may remain intact in many patients [1, 2]. HD is an autosomal dominant neurological disorder caused by an expanded tandem array (>35 repeats) of CAG codons within exon 1 of the HTT gene [5, 6]. An inverse relationship exists between repeat number and onset age of symptoms. The CAG repeat length tends to expand as the trait is passed down through inheritance, accounting for the earlier onset of symptoms in successive generations, known as anticipation. Many reviews describing HD exist, see [10, 11] for recent summaries
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